Sickle cell disease is a progressive vasculopathy stemming from decreased red blood cell (RBC) deformability. Vascular disease is at the heart of both acute and chronic sickle disease, including pain crisis, acute chest syndrome, stroke, skin ulcers, and pulmonary hypertension. However, the mechanisms linking decreased RBC deformability to chronic vasculopathy are multifactorial and poorly characterized. Nitric oxide (NO) is the key mediator linking blood mechanics to vessel tone and vascular remodeling. As bloodflow shears the endothelium, NO is released, causing vasodilation and inhibiting platelet aggregation. NO bioavailability is diminished in SCD because decellularized hemoglobin and arginase, released during hemolysis, scavenge NO and lower endothelial NO production. Recent evidence suggests that 50% of bioavailable NO is synthesized within RBC, themselves, though a shear-activated eNOS enzyme. RBC NO is primarily converted to nitrite and nitrosylated hemoglobins when tissue oxygenation is high, but deoxygenated hemoglobin converts these species to nitric oxide under hypoxic conductions. Thus, RBC generated NO appears to be a vital mediator of oxygen supply and demand and its role in sickle cell vasculopathy is completely unexplored. Our fundamental hypothesis is that decreased red cell deformability reduces shear-mediated nitric oxide production by the red cell itself, crippling vita storage forms of nitric oxide, causing vascular dysfunction at several levels of the vascular system. This research proposal merges novel laboratory methods in RBC nitric oxide production with clinical investigation of vascular dysfunction in patients with sickle cell disease Multimodal characterization of the different vascular beds will lead to improved phenotypic categorization and pathophysiological links to the underlying RBC biophysical/biochemical derangements. We will also explore whether RBC-generated NO has the ability to directly affect the vasculature using aortic ring preps and whether RBC-generated NO decreases platelet aggregation. Support from this grant benefits SCD patients in three ways: 1) it improves cross- specialization (i.e. hematology and cardiology), 2) it translates novel lab based methods in RBC generation of NO to patients using vascular preps and measurement of platelet aggregation, and 3) it will set the ground work for larger clinical translational studies linking RBC-generated NO and rheology with sophisticated measures of vascular function in patients with SCD. The K23 mechanism represents the natural extension my career development to date, combining my previous laboratory and patient-oriented research expertise with the specific clinical research training necessary to conduct large translational studies of novel targets in vascular dysfunction.